Three-dimensional evaluation of TMJ parameters in Class II and Class III patients Zane Krisjane, Ilga Urtane, Gaida Krumina, Katrina Zepa

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1 Stomatologija, Baltic Dental and Maxillofacial Journal, 11: 32-36, 2009 Three-dimensional evaluation of TMJ parameters in Class II and Class III patients Zane Krisjane, Ilga Urtane, Gaida Krumina, Katrina Zepa SUMMARY The aim of our study was to assess condylar parameters and condyle position within glenoid fossa of TMJ in volumetric 3D imaging in patients with Class II and Class III malocclusions. Materials and methods. The study group included 15 patients with severe skeletal Class II (mean age 18.0 yrs) and 14 patients with severe skeletal Class III ( mean age 19,2 yrs) with an indication for combined orthodontic and orthognathic treatment. CT examination was performed, pictures were reconstructed in three dimensional (3D) rendering and measured in two dimension projection (2D) pictures using IAC review and Transparent bone programs to quantify following condylar and glenoid fossa parameters glenoid fossa width and height; tuberculum articulare angle; anterior, superior and posterior joint space; height and width of condyle, height of procesus condylaris. Mean values were calculated separately for left and right side. Differences of the mean values were tested using paired t-test. Results. There were statistically significant differences (p<0,05) between two study groups for all spatial measurements on both sides with larger spatial measurements in patients with Class II malocclusions. Also the height of procesus condylaris varied between groups with statistical difference. Unilateral differences were detected for width of fossa glenoidale and height of condyle. Conclusion. Results show that there are a tendency for smaller condyle and wider spaces between condyle and walls of glenoid fossa comparing TMJ of Class II with Class III patients. Key words: condyle, glenoid fossa, temporomandibular joint, multi-slice computed tomography. INTRODUCTION In literature it has been hypotized that the condyle and the fossa might differ in shape and their interrelations among people with various malocclusions while the mandible and the temporomandibular joint can be loaded differently in persons with diverse dentofacial morphologies [1]. Several studies with conventional tomography methods have been done to find the relations between skeletal malocclusions Class II and Class III- and 1 Department of Orthodontics, Institute of Stomatology, Riga Stradins University 2 Institute of Radiology, Riga Stradins University, Zane Krisjane 1 PhD student in orthodontics Ilga Urtane 1 D.D.S., DrMed, Professor, Head of Department of Orthodontics, Rigas Stradins University Gaida Krumina 2 M.D.PhD., Professor, Director of Institute of Radiology Katrina Zepa 1 PhD student in orthodonics Address correspondence to: Zane Krisjane, Department of Orthodontics, Institute of Stomatology, Rigas Stradins University, 20 Dzirciema street, Riga, Latvia, LV address: krisjane.zane@inbox.lv some features of temporomandibular joint (TMJ) but the results are not homogeneous. The influence of occlusion on joint morphology is still not completely understood, authors like Mongini [2], Pullinger [3], O Byrn [4] found positive correlations but Cohlmia [5] failed to find any correlations. It is not also clear, what is the condyle position within the fossa in various malocclusions, are there any differences and if yes- are they a cause or a result of the occlusion, since TMJ parts do not grow in unison some follow a cranial and others a facial growth plane [6]. Difficulties in visualization of the TMJ to its complex anatomy and superimposition of adjacent structures might be a factor, responsible for the discrepancies in the results of different studies concerning TMJ, where conventional tomography as a method of investigation was used. Nowadays other methods are used for evaluating 3-dimensional morphology of the skeletal structures of TMJ-cone beam computed tomography (CBCT) and 32 Stomatologija, Baltic Dental and Maxillofacial Journal, 2009, Vol. 11, No. 1

2 Z. Krisjane et al. B A Fig. 1. Anterior, superior and posterior joint space multi slice computed tomography (MSCT). Both of them provide an optimal imaging of the osseous components of the TMJ [7] and gives a full size truly volumetric 3D description in real anatomical (1:1) size [8;9]. Aim The aim of our study was to assess condylar parameters and condyle position within glenoid fossa of TMJ in volumetric 3D imaging in patients with Class II and Class III malocclusions before orthodontic and orthognatic treatment. MATERIALS AND METHODS Our study included 15 patients with skeletal Class II (mean age 18.0 years) and 14 patients with skeletal Class III (mean age 19.2 years). The inclusion criteria for Class II patients were: overjet more than 6 mm, increased ANB angle; for Class III patients overjet less than 0 mm, ANB angle 0 degrees. All patients had the indication for combined orthodontic treatment and orthognathic surgery. They had no evident facial Fig. 2. Glenoid fossa width and height asymmetry, no functional mandibular deviations nor rheumatoid or traumatic symptoms. Symptoms of temporomandibular disorders were not considered in selecting these subjects and they had not undergone previous orthodontic treatment. Conventional clinical and radiological examination of occlusion and of TMJ was used Before starting preorthognathic orthodontic treatment, 3D CT investigation was performed using GE Medical Systems Light Speed Pro 16CT99_Oc0 system. The position of the patient was lying on the back, head positioned in the middle of orbitomeatal plane, closed mouth position direct touch of molar teeth in habitual occlusion. Axial scanning was done from soft tissue point Glabella down to upper margin of C6. CT scan protocol helical full 1.0 s, slice thickness mm, pitch mm, reconstruction bone and soft tissue using IAC Review and Transparent bone programs. Following measurements were done: anterior, superior and posterior joint space the shortest distance between most prominent point of condyle in each di- C Table 1. Mean values of condylar and glenoid fossa measurements between Class II and Class III left and right side Class II Class III Measurements Rigth side Left side Right side Left side Mean SD Mean SD Mean SD Mean SD Height of fossa glenoidale Width of fossa glenoidale * 1.65 Tuberculum articulare angle Anterior joint space 2.1* * Superior joint space 2.8* * Posterior joint space 3.8* * Width of tub. Articulare Height of condyle 4* Width of condyle Height of proc. Condylaris * * 2.59 * statistically significant in comparison between groups. Stomatologija, Baltic Dental and Maxillofacial Journal, 2009, Vol. 11, No. 1 33

3 Z. Krisjane et al. SCIENTIFIC ARTICLES Fig. 3. Width and height of condyle rection and accordingly anterior, superior or posterior point in walls of glenoid fossa (Fig. 1); glenoid fossa width the distance from the most superior point of the fossa to the plane formed by the most inferior point of the articular tubercle to the most inferior point of auditory meatus (Fig. 2), glenoid fossa height the distance between the top of tuberculum articulare and procesus postglenoidalis (Fig.2); Tuberculum articulare angle angle between the plane of the posterior wall of the articular tubercle and the plane obtained from the most inferior point of the articular tubercle to the most inferior point of the auditory meatus; height of condyle linear distance between top of the condyle and crossectional line (Fig. 3); width of condyle linear distance between most anterior and posterior point of condyle ( see Fig. 3); height of processus condylaris linear distance between the highest point of condyle and line that goes through mandibular incisura (Fig. 4). According to Pullinger et al. [10], position of mandibular condyle was described as anterior, concentric or posterior, what was calculated by means of following equation: Linear ratio = (P-A)/ (P+A) x 100 P The closest posterior measurement A The closest anterior measurement LR<-12 posterior position -12< LR<12 concentric position LR>12 anterior position Study was approved by Riga Stradins University Ethical committee. Statistical analysis All the measurements were done by one operator two times with a time interval two weeks. Fig. 4. Height of processus condylaris Intraobserver measurement error was 0.8. The mean values of those measurements were used for the statistical analysis. Mean values of condyle and glenoid fossa measurements were calculated separately for left and right side. Differences of mean values were tested using t- test. RESULTS The average values of condylar and glenoid fossa measurements are given in Table 1. As showed results in Table 2, no statistically significant differences were observed between both groups in condyle width, but height of the condyle on right side was bigger in Class II group (p=0.0231). Also the measurements for glenoid fossa and articular tubercle did not show any differences, except the width of glenoid fossa on left side it seems to be wider in Class III cases (p=0.0219). Statistically significant differences of length of processus condylaris (p=0.0027; p=0.0004) on both sides were detected between groups, showing this anatomical structure to be longer in Class III cases. Table 2. Comparison between Class II and Class III for right and left side (p 0.05) Differences in mean values between Class II and Class III Right side (p) Left side (p) Height of fossa glenoidale NS NS Width of fossa glenoidale NS Tuberculum articulare angle NS NS Width of tub. Articulare NS NS Height of condyle NS Width of condyle NS NS Height of proc. Condylaris NS the difference is not statistically significant. 34 Stomatologija, Baltic Dental and Maxillofacial Journal, 2009, Vol. 11, No. 1

4 All the spatial measurements showed statistically significant differences, when comparing Class II with Class III (Table 3.). Our results were calculated for each TMJ side separately (Class II 30 joints and Class III 28 joints together) and they showed that condyles are more anteriorly positioned in both groups, followed by concentric position. Posterior position was observed only in few joints in both groups (Table 4.). DISCUSSION In orthodontics it is widely accepted that function affects form and it can be also referred to the occlusion and temporomandibular joint morphology. Our results do not show great differences in skeletal morphology of joint between two study groups. According to Arnett [11], large condyles provide stable support for occlusal changes; they are associated with many Class III malocclusions and also some Class II. Condyles are considered to be more resistant to displacement because of the tight fit of the fossa and condyle. Inversely small condyles provide unreliable support for occlusal changes, are frequently associated with Class II malocclusion and are easily displaced because condyle, fossa and capsule fit are loose. In morphometric tomographic study where they compared condyle and fossa shape between various skeletal patterns, no condyle size differences were observed between Class II/1 and Class II/2 cases, in Class III group condyle was more elongated [1]. Our findings indicate that the height of condyle was asymmetrically higher in Class II cases, respectively, on the right side, with statistical significance (p=0.0231). There was no statistically significant difference observed condyle width in both groups. Statistically significant difference of length of procesus condylaris was observed between groups in Class III cases Table 3. Comparison of glenoid fossa and condyle distance measurements between Class II and Class III (p 0. 05) Measurement Right side (p) Left side (p) Anterior joint space Superior joint space Posterior joint space Table 4. Condylar position in Class II and Class III cases Position Class II Class III No. of % No. of % joints joints Anterior Concentric Posterior Total No. of examined joints Z. Krisjane et al. the procesus condylaris of mandible is longer, what probably indicates to excessive vertical development of mandibular ramus what has happened during growth. Also the measurements for glenoid fossa do not show remarkable differences between both groups, except width of fossa glenoidale on the left side- it seems to be wider in Class III cases. In literature where the height of fossa glenoidale has been compared between various occlusions respectively Class II and Class I, no statistically significant differences were observed [12]. Katsavrias et al. found that Class III group has a wider but more flattened glenoid fossa when comparing with Class II [1], what partly goes in line with our findings. All the spatial measurements were larger in Class II group with statistically significant difference, what supports Arnett [11] and can be a reason for increased joint laxity in mandibular deficiency cases [13]. The position of the mandibular condyle was described as anterior, concentric or posterior. Results show, that condyles are more anteriourly positioned in both groups. Pullinger et al found that Class II malocclusion was associated with more nonconcentric condylar positions than Class I, with the position in Class II/1 being more frequently anterior [3]. Gianelly et. al [14] found that the condyles of click-free persons with Class II molar relationships, deep bites and no overjets were positioned concentricaly in the fossae. In literature condyle position has been analyzed more in connection with different TMJ and articular disc problems rather than with different malocclusions. Nonconcentric condyle-fossa relationships are associated with abnormal TMJ function and conversely asymptomatic subjects have been characterized by more concentric positions [3]. Pullinger, 1987 investigated 74 asymptomatic joints, which represent normal population and the results were 43% concentric, 27% posterior and 30% anterior. Evidently there is no clear statement in the literature how condyle position is affected by different skeletal malocclusions. Also our findings show only a tendency for condyles being more anteriorourly positioned in both groups while the number of examined joints is too small to find stronger proofs. CONCLUSIONS Due to some limitations this study must be considered preliminary and may be subjected to further progressing. Nevertheless, the advantages of 3D CT imaging analysis relative to conventional CT for deter- Stomatologija, Baltic Dental and Maxillofacial Journal, 2009, Vol. 11, No. 1 35

5 Z. Krisjane et al. SCIENTIFIC ARTICLES mine TMJ morphology give for our study high validity. Following conclusions can be done: 1. Methods of investigation of TMJ used in our study are accepted for further imposition 2. Even in patients without clinically evident asymmetries, asymmetries in joint structures can be detected 3. No remarkable differences in condyle size were observed between patients with skeletal Class II and Class III 4. TMJ laxity is increased in cases of Class II malocclusions 5. In both groups condyles are more anteriourly positioned, what indicate to different malocclusion role in non-concentric condyle placement. REFERENCES 1. Katsavrias EG, Halazonetis DJ. Condyle and fossa shape in Class II and Class III skeletal patterns: A morphometric tomographic study. Am J Orthod Dentofacial Orthop 2005:128: Mongini F, Schmid W. Treatment of mandibular asymmetries during growth. Eur J Orthod 1987;9: Pullinger A, Solberg W, Hollender L, Petersson A. Relationship of mandibular condyle position to dental occlusion factors in an asymptomatic population. Am J Orthod Dentofacial Orthop 1987;91: O Byrn BL, Sadowsky C, Schneider B, Begole EA. An evaluation of mandibular asymmetry in adults with unilateral posterior crossbite. Am J Orthod Dentofacial Orthop 1995;107: Cohlmia JT, Ghosh J, Sinha PK, Nanda RS, Currier GF. Tomograpfic assessment of temporomandibular joints in patients with malocclusion. Angle Orthod 1996; 66: Katsavrias EG. Morphology of temporomandibular joint in subjects with Class II Division 2 malocclusion. Am J Orthod Dentofacial Orthop 2006:129: Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear temporomandibular joint measurements with cone beam computed tomography and digital cephalometric radiography. Am J Orthod Dentofacial Orthop 2005:128: Swennen GR, Schutyser F. Three- dimensional cephalometry: spiral multi slice vs.cone- beam computed tomography. Am J Orthod Dentofacial Orthop 2006:130: Swennen GR, Schutyser F, Barth EL, Groeve P, Mey AD. A new method of 3-D cephalometry Part I: The Anatomy Cartesian 3-D Reference system. J Craniofac Surg 2006:17: Pullinger A, Hollender L. Variation in condyle- fossa relationships according to different methods of evaluation in tomograms. Oral Surg Oral Med Oral Pathol 1986;62: Arnett W, McLaughlin RP. Facial and Dental Planning for Orthodontists and Oral Surgeons. Mosby; 2004, p Vitral RWF, Telles CS, Fraga MR, Fortes de Oliveira RSM, Tanaka OM. Computed tomography evaluation of temporomandibular joint alterations in patients with Class II Division 1 subdivision malocclusions: Condyle- fossa relationship. Am J Orthod Dentofacial Orthop 2004:126: Pullinger AG, Seligman DA, John MT, Harkins S. Multifactorial comparison of disk displacement with and without reduction to normals according to temporomandibular joint hard tissue anatomic relationships. J Prosthet Dent 2002:87: Gianelly AA, Petras JC, Boffa J. Condylar position and Class II deep- bite, no overjet malocclusions. Am J Orthod Dentofacial Orthop 1989:96: Received: Accepted for publishing: Stomatologija, Baltic Dental and Maxillofacial Journal, 2009, Vol. 11, No. 1

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